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            <h2>脑血管疾病筛查</h2>
            <div>感谢您的关注！脑血管病目前是全球范围内危害人类健康的第一位杀手,
                筛查预防是降低脑血管病发病率的重要方法。以下是一份脑血管病危险因素的筛查问卷，
                为了您和家人的健康，请您认真作答，其中非必填项如果您不确定，可以不必作答。谢谢！
                <span style="font-weight: bolder">联系电话:0931-8365350</span>
            </div>
            <div style="margin-top: 3%;float: right">
                <p style="text-align: center;">兰州市脑血管病诊治中心</p>
                <p style="text-align: center;">兰州市第二人民医院卒中中心</p>
            </div>
        </div>
        <ul id="fields" class="fields">
            <li class=" fieldInstruct one" type="text" reqd="1"><label
                    class="desc">姓名：</label>
                <div class="content">
                    <input id="name" type="text" maxlength="256" name="name" class="input fld m"/>
                    <input id="id" name="id" type="hidden">
                </div>
            </li>
            <li  class=" fieldInstruct one" type="text" reqd="1"><label
                    class="desc">年龄：<span class="req">*</span></label>
                <div class="content">
                    <input id="age" type="number" max="150" name="age" class="input fld m" required="required"/>
                </div>
            </li>
            <li  class=" fieldInstruct one" type="checkbox" reqd="1"><label class="desc">性别：
                <span class="req">*</span></label>
                <div class="content pretty-box">
                    <span><input class="fld" id="F2" type="radio" name="sex" value="男"/><label for="F2">男</label></span>
                    <span><input class="fld" id="F3" type="radio" name="sex" value="女"/><label for="F3">女</label></span>
                </div>
            </li>
            <li class=" fieldInstruct one" type="text" reqd="1"><label class="desc">民族：
                <span class="req">*</span></label>
                <div class="content">
                    <input id="mz" type="text" maxlength="256" name="mz" class="input fld m" required="required"/>
                </div>
            </li>
            <li class=" fieldInstruct one" tyep="checkbox" reqd="1"><label class="desc">文化程度：
                <span class="req">*</span></label>
                <div class="content pretty-box">
                    <span><input class="fld" id="xl1" type="radio" name="xl" value="本科及以上"/><label
                            for="xl1">本科及以上</label></span>
                    <span><input class="fld" id="xl2" type="radio" name="xl" value="大专或中专或技校"/><label for="xl2">大专或中专或技校</label></span>
                    <span><input class="fld" id="xl3" type="radio" name="xl" value="高中初中"/><label for="xl3">高中初中</label></span>
                    <span><input class="fld" id="xl4" type="radio" name="xl" value="小学及以下"/><label
                            for="xl4">小学及以下</label></span>
                </div>
            </li>
            <li class=" fieldInstruct one" typ="checkbox" reqd="1"><label class="desc">职业： <span class="req">*</span></label>
                <div class="content">
                    <input id="job" type="text" maxlength="256" name="job" class="input fld m" required="required"/>
                </div>
            </li>
            <li  class=" fieldInstruct one" typ="checkbox" reqd="1"><label class="desc">居住地：
                <span class="req">*</span></label>
                <div class="content">
                    <input id="address" type="text" maxlength="256" name="address" class="input fld m"
                           required="required"/>
                </div>
            </li>
            <li class=" fieldInstruct one" typ="radio" reqd="1"><label class="desc">家族中人是否有脑血管病的患病史：
                <span class="req">*</span></label>
                <div class="content pretty-box">
                    <span><input class="fld" id="t9" type="radio" name="nxgbhistory" value="有"/><label for="t9">有</label></span>
                    <span><input class="fld" id="t10" type="radio" name="nxgbhistory" value="没有"/><label for="t10">没有</label></span>
                </div>
            </li>
            <li class=" fieldInstruct one" typ="radio" reqd="1"><label class="desc">本人是否有脑卒中（脑缺血/脑出血）病史：
                <span class="req">*</span></label>
                <div class="content pretty-box">
                    <span><input class="fld" id="t90" type="radio" name="nzbhistory" value="有"/><label for="t90">有</label></span>
                    <span><input class="fld" id="t100" type="radio" name="nzbhistory" value="没有"/><label for="t100">没有</label></span>
                </div>
            </li>
            <li  class=" fieldInstruct one" typ="dropdown2" reqd="1"><label class="desc">本人是否有确诊过的短暂性脑缺血发作(TIA)病史：
                <span class="req">*</span></label>
                <div class="content pretty-box">
                    <span><input class="fld" id="t13" type="radio" name="heartRadio" value="否"/><label
                            for="t13">否</label></span>
                    <span><input class="fld" id="t14" type="radio" name="heartRadio" value="是"/><label for="t14">是</label></span>
                </div>
            </li>
            <li  class=" fieldInstruct one" typ="dropdown2" reqd="1"><label class="desc">是否有过一过性黑朦、视力丧失、视野缺损或复视：
            </label>
                <div class="content pretty-box">
                    <span><input class="fld" id="t15" type="radio" name="hm" value="否"/><label for="t15">否</label></span>
                    <span><input class="fld" id="t16" type="radio" name="hm" value="是"/><label for="t16">是</label></span>
                </div>
            </li>
            <li class=" fieldInstruct one" typ="dropdown2" reqd="1"><label class="desc">是否有过一过性失语、识读或失写：
            </label>
                <div class="content pretty-box">
                    <span><input class="fld" id="t17" type="radio" name="sy" value="否" /><label for="t17">否</label></span>
                    <span><input class="fld" id="t18" type="radio" name="sy" value="是"/><label for="t18">是</label></span>
                </div>
            </li>
            <li class=" fieldInstruct one" typ="dropdown2" reqd="1"><label class="desc">是否有过一过性单侧或双侧肢体无力、感觉异常：
            </label>
                <div class="content pretty-box">
                    <span><input class="fld" id="t19" type="radio" name="wl" value="否"/><label for="t19">否</label></span>
                    <span><input class="fld" id="t20" type="radio" name="wl" value="是"/><label for="t20">是</label></span>
                </div>
            </li>
            <li class=" fieldInstruct one" typ="dropdown2" reqd="1"><label class="desc">是否有过一过性听力下降、瘫痪、意识障碍或猝倒发作：
            </label>
                <div class="content pretty-box">
                    <span><input class="fld" id="t21" type="radio" name="xj" value="否"/><label for="t21">否</label></span>
                    <span><input class="fld" id="t22" type="radio" name="xj" value="是"/><label for="t22">是</label></span>
                </div>
            </li>
            <li class=" fieldInstruct one" typ="dropdown2" reqd="1"><label class="desc">高血压病：
                <span class="req">*</span></label>
                <div class="content pretty-box">
                    <span><input class="fld" id="t23" type="radio" name="gxy" value="否" /><label for="t23">否</label></span>
                    <span><input class="fld" id="t24" type="radio" name="gxy" value="是"/><label for="t24">是</label></span>
                </div>
            </li>
            <li class=" fieldInstruct" typ="text" reqd="1"><label class="desc">血压(单位：mmHg)： <span
                    class="req">*</span></label>
                <div class="content">
                    <p class="instruct">收缩压</p>
                    <input id="pressMed" type="number" max="200" name="pressMed" class="input fld m" value="0" required="required"/>
                    <p class="instruct">舒张压</p>
                    <input id="szy" type="number" max="200"  name="szy" class="input fld m" value="0" required="required"/>
                </div>
            </li>
            <li class=" fieldInstruct one" typ="radio" reqd="1"><label class="desc">是否正在服用降压药物：
                <span class="req">*</span></label>
                <div class="content pretty-box">
                    <span><input class="fld" id="t25" type="radio" name="pressMedRadio" value="0"/><label for="t25">否</label></span>
                    <span><input class="fld" id="t26" type="radio" name="pressMedRadio" value="1"/><label for="t26">是</label></span>
                </div>
            </li>
            <li class=" fieldInstruct one" typ="radio" reqd="1"><label class="desc">糖尿病：
                <span class="req">*</span></label>
                <div class="content pretty-box">
                    <span><input class="fld" id="t27" type="radio" name="tnb" value="0" /><label
                            for="t27">否</label></span>
                    <span><input class="fld" id="t28" type="radio" name="tnb" value="1"/><label for="t28">是</label></span>
                </div>
            </li>
            <li class=" fieldInstruct" typ="text"><label class="desc">空腹血糖： </label>
                <div class="content">
                    <p id="p6" class="instruct">输入示例：5.5mmol/L</p>
                    <input id="heartMedRadio" type="number" max="10" name="heartMedRadio" step="0.1" class="input fld m"/>
                </div>
            </li>
            <li  class=" fieldInstruct" typ="text"><label class="desc">餐后2小时血糖：</label>
                <div class="content">
                    <p class="instruct">输入示例：5.5mmol/L</p>
                    <input id="bloodSugar2h" type="number" max="10" step="0.1"  name="bloodSugar2h" class="input fld m" />
                </div>
            </li>
            <li class=" fieldInstruct" typ="text"><label class="desc">随机血糖： </label>
                <div class="content">
                    <p id="p7" class="instruct">输入示例：5.5mmol/L</p>
                    <input id="sjxt" type="number" max="10" step="0.1"  name="sjxt" class="input fld m" />
                </div>
            </li>
            <li  class=" fieldInstruct one" typ="radio" reqd="1"><label class="desc">是否有房颤或瓣膜性心脏病：
                <span class="req">*</span></label>
                <div class="content pretty-box">
                    <span><input class="fld" id="t29" type="radio" name="fc" value="否"/><label for="t29">否</label></span>
                    <span><input class="fld" id="t30" type="radio" name="fc" value="是"/><label for="t30">是</label></span>
                </div>
            </li>
            <li id="5c1d907f75a03c456040cb23" class=" fieldInstruct one" typ="radio" reqd="1"><label class="desc">每周运动≧3次，每次中等强度及以上运动≧30分钟，或从事中、重度体力劳动：
                <span class="req">*</span></label>
                <div class="content pretty-box">
                    <span><input class="fld" id="t31" type="radio" name="yd" value="否"/><label for="t31">否</label></span>
                    <span><input class="fld" id="t32" type="radio" name="yd" value="是"/><label for="t32">是</label></span>
                </div>
            </li>
            <li  class=" fieldInstruct" typ="text" reqd="1"><label class="desc">吸烟指数： <span
                    class="req">*</span></label>
                <div class="content">
                    <p id="p19" class="instruct">输入提示：支/日 x 吸烟年限，若不吸烟填写0</p>
                    <input id="smoke1" v-model="smoke1" type="number" min="0" class="input fld m" style="width:48%;"
                           placeholder="支/日" required="required"  onkeyup="value=value.replace(/[^\d.]/g,'')"/>
                    <input id="smoke2" v-model="smoke2" type="number" max="100" min="0" class="input fld m" style="width:48%;"
                           placeholder="吸烟年限" required="required" onkeyup="value=value.replace(/[^\d.]/g,'')"/><br>
                    <label for="smoke" class="instruct">您的吸烟指数为：</label>
                    <input id="smoke" :value="smoke" name="smoke" readonly class="input fld m instruct" style="width: 20%"/>
                </div>
            </li>
            <li id="5c20338ffc918f4de7f2db32" class=" fieldInstruct" typ="text" reqd="1"><label class="desc">饮酒指数: <span
                    class="req">*</span></label>
                <div class="content">
                    <p id="p20" class="instruct">输入提示：g/日 x 饮酒年数（45~55度白酒），若不饮酒填写0</p>
                    <input id="drinkId1" v-model="drinkId1" type="number" min="0" class="input fld m" style="width:48%;"
                           placeholder="g/日" required="required" onkeyup="value=value.replace(/[^\d.]/g,'')"/>
                    <input id="drinkId2" v-model="drinkId2" type="number" max="100" min="0" class="input fld m" style="width:48%;"
                           placeholder="饮酒年限" required="required" onkeyup="value=value.replace(/[^\d.]/g,'')"/><br>
                    <label for="drink" class="instruct">您的饮酒指数为：</label>
                    <input id="drink" :value="drink" readonly name="drink" class="input fld m instruct" style="width: 20%"/>
                </div>
            </li>
            <li id="5c2034a3fc918f4de7f2dd89" class=" fieldInstruct" typ="text" reqd="1"><label class="desc">体重指数（BMI）:
                <span class="req">*</span></label>
                <div class="content">
                    <p id="p21" class="instruct">输入提示：体重指数（BMI）=体重kg/身高（m）&sup2;</p>
                    <input id="bmi1" v-model="bmi1" type="text" max="250" min="0" class="input fld m" style="width:48%;"
                           placeholder="体重（kg）" required="required" onkeyup="value=value.replace(/[^\d.]/g,'')"/>
                    <input id="bmi2" v-model="bmi2" type="text" max="300" min="0" class="input fld m" style="width:48%;"
                           placeholder="身高（m）" required="required" onkeyup="value=value.replace(/[^\d.]/g,'')"/><br>
                    <label for="drink" class="instruct">您的BMI指数为：</label>
                    <input id="bmi" :value="bmi" readonly name="bmi" class="input fld m instruct" style="width: 20%"/>
                    <label for="biaozhun" class="instruct">中国参考标准： 18.5-BMI-24 </label>
                    <input id="biaozhun" :value="biaozhun" disabled class="input fld m instruct" style="width: 20%;border: none"/>
                </div>
            </li>
            <li class=" fieldInstruct" typ="text"><label class="desc">血脂：</label>
            </li>
            <li  class=" fieldInstruct" typ="text"><label class="desc">总胆固醇：</label>
                <div class="content">
                    <p  class="instruct">输入示例：1.7mmol/L</p>
                    <input id="zdgc" type="number" max="10" step="0.1"  name="zdgc" class="input fld m"/>
                </div>
            </li>
            <li  class=" fieldInstruct" typ="text"><label class="desc">甘油三脂</label>
                <div class="content">
                    <p  class="instruct">输入示例：1.7mmol/L</p>
                    <input id="gysz" type="number" max="10" step="0.1"  name="gysz" class="input fld m"/>
                </div>
            </li>
            <li  class=" fieldInstruct" typ="text"><label class="desc">低密度脂蛋白：</label>
                <div class="content">
                    <p  class="instruct">输入示例：1.7mmol/L</p>
                    <input id="dmdzdb" type="number" max="10" step="0.1"  name="dmdzdb" class="input fld m" />
                </div>
            </li>
            <li  class=" fieldInstruct" typ="text"><label class="desc">高密度脂蛋白：</label>
                <div class="content">
                    <p  class="instruct">输入示例：1.7mmol/L</p>
                    <input id="gmdzdb" type="number" max="10" step="0.1"  name="gmdzdb" class="input fld m" />
                </div>
            </li>
            <li  class=" fieldInstruct" typ="text"><label class="desc">血清同型半胱氨酸：</label>
                <div class="content">
                    <p id="p10" class="instruct">输入示例：10μmol/L</p>
                    <input id="txbgas" type="number" max="10" step="0.1"  name="txbgas" class="input fld m"/>
                </div>
            </li>
            <li class=" fieldInstruct one" typ="radio" reqd="1"><label class="desc">颈动脉超声检查：</label>
            </li>
            <li class=" fieldInstruct one" typ="radio"><label class="desc">是否有斑块或狭窄：</label>
                <div class="content pretty-box">
                    <span><input class="fld" id="t33" type="radio" name="jdmbkCheck" value="有"/><label for="t33">有</label></span>
                    <span><input class="fld" id="t34" type="radio" name="jdmbkCheck" value="没有"/><label for="t34">没有</label></span>
                </div>
            </li>
            <li class=" fieldInstruct" typ="text"><label class="desc">颈动脉血管狭窄率(%)：</label>
                <div class="content">
                    <input id="jdmxzl" type="number" maxlength="99" step="0.1"  name="jdmxzl" class="input fld m"/>
                </div>
            </li>
            <li class=" fieldInstruct one" typ="radio" reqd="1"><label class="desc">经颅多普勒检查：</label>
            </li>
            <li  class=" fieldInstruct one" typ="radio"><label
                    class="desc">是否有颅内血管狭窄：</label>
                <div class="content pretty-box">
                    <span><input class="fld" id="t35" type="radio" name="lnxgxzRadio" value="有"/><label
                            for="t35">有</label></span>
                    <span><input class="fld" id="t36" type="radio" name="lnxgxzRadio" value="没有"/><label
                            for="t36">没有</label></span>
                </div>
            </li>
            <li  class=" fieldInstruct" typ="text"><label class="desc">颅内血管狭窄率(%)：</label>
                <div class="content">
                    <input id="lnxgxzl" type="number" maxlength="99" step="0.1"  name="lnxgxzl" class="input fld m"/>
                </div>
            </li>
            <li class=" fieldInstruct one" typ="radio" reqd="1"><label class="desc">头颈血管CTA检查：</label>
            </li>
            <li  class=" fieldInstruct one" typ="radio"><label class="desc">是否有斑块或狭窄：</label>
                <div class="content pretty-box">
                    <span><input class="fld" id="t37" type="radio" name="jdmctabkCheck" value="有"/><label
                            for="t37">有</label></span>
                    <span><input class="fld" id="t38" type="radio" name="jdmctabkCheck" value="没有"/><label
                            for="t38">没有</label></span>
                </div>
            </li>
            <li class=" fieldInstruct" typ="text"><label class="desc">颈部动脉狭窄率(%)：</label>
                <div class="content">
                    <input id="jdmCTAxzl" type="number" max="99" step="0.1"   name="jdmCTAxzl" class="input fld m"/>
                </div>
            </li>
            <li  class=" fieldInstruct" typ="text"><label class="desc">颅内血管狭窄率(%)：</label>
                <div class="content">
                    <input id="ctalnxgxzl" type="number" max="99" step="0.1"   name="ctalnxgxzl" class="input fld m"/>
                </div>
            </li>
            <li  class=" fieldInstruct" typ="text" reqd="1"><label
                    class="desc">联系方式(为了能反馈和随访您的筛查结果，请留下您的联系方式!): </label>
            </li>
            <li  class=" fieldInstruct" typ="text" reqd="1"><label
                    class="desc">手机: </label>
                <div class="content">
                    <input id="phone" type="text" maxlength="256" name="phone" class="input fld m" />
                </div>
            </li>
            <li  class=" fieldInstruct" typ="text" reqd="1"><label
                    class="desc">Email: </label>
                <div class="content">
                    <input id="email" type="email" maxlength="256" name="email" class="input fld m" />
                </div>
            </li>

            <li id="5c2034a3fc918f4de7f2dd8a" class=" fieldInstruct" typ="textarea" reqd="1"><label class="desc">其他说明：
            </label>
                <div class="content">
                    <p class="instruct">若没有其他说明，不必填写</p>
                    <textarea id="other" name="other" class="input fld s" ></textarea>
                </div>
            </li>
            <li class=" fieldInstruct" typ="textarea">
                <div class="content" style="text-align: center">
                    <img src="images/gzh.jpg">
                </div>
            </li>
            <li class="pc-submit"><input id="btnSubmit" type="submit" class="btn-submit"
                                         style="background-color:#0099ff" value="提交"/></li>
        </ul>
    </form>
</div>
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